Journal of Korean Academy of (2001) Vol. 31, No. 7 Comparison of the Home Care System for the Elderly in and Korea: Towards an Advanced Home Care System

Jeung-im Kim, RN, PhD1, Sachiyo Murashima, PhD, RN, PHN2

The purpose of this study is to provide the directions for the further development of the home care services in Korea, through comparison of the home care system and visiting nursing activities for the elderly in Japan and with those of Korea. The results of this study were summarised as follows: The major difference between the two countries was that Japan emphasised the development of home services by visiting nurse service stations (VNSS), especially in the community. In contrast, Korea has emphasised provid- ing hospital based home care services and assuring the quality of services through the preparation of home care nurses before beginning services. And many elderly in Korea have used a public health center when they have health problems. According to the result, the establishment of a VNSS system and activation of a public health center in the com- munity must be considered as the direction to advance home care systems for the elderly. Key Words: Home care; Elderly; Korea; Japan

toward a home care system (HCS) for the elderly more INTRODUCTION pressing and has triggered the need for changes to make the system more available and more conve- The number of elders in the population is increasing all nient in both countries. over the world; it first occurred in Europe, and now also The most prominent change of the care environment has become a reality in Asia. Coping with ageing and in Japan is that the “Home” has been accredited as a changing the social system appropriately is one of the field in 1994, and home visit service is now covered by big issues in the world today. health insurance. In Korea, home care has been provided Japan and Korea are both Asian countries located in from 1990 at the public level guaranteeing health care to the far-eastern part of Asia. Both confronted the ageing the elderly at home. And it also “home” has been ac- of their societies earlier than other Asian countries. The credited as a field in April 2000 (Medical law, 2000). percentage of elderly people in was 16.7 However, there are differences between the systems percent the largest among Asian countries (JHWSA, for home care services in the two countries. Though 1999a). In Korea, it was seven percent in 2000 (KNSO, home visiting nursing was started at the hospital level, it 2000), a point had reached by Japan in 1970. Korea is has been expanded to the community level in Japan, projected to be an ‘Aged Society’ by 2022 (KNSO, while Korea has advocated home care at the hospital lev- 1997). el as a problem solving strategy. These differences reflect This rapid change has made the importance of moving differences in the social, cultural and demographic char-

1. Department of Women’s Health Nursing, School of Nursing, College of Medicine, Soonchunhyang University 2. Department of Community Health Nursing, Graduate School of Medicine, The University of , Corresponding author: Jeung-im Kim, PhD, RN. Assistant Professor, Department of Nursing Soonchunhyang University Tel: 8241-530-1357 Fax: 8241-574-3860 E-mail: [email protected] Received September 3, 2001 ; Accepted December 21, 2001 Kim et al. Comparison HCS Japan and Korea 1167 acteristics of each country but there is still a need to find vere disability to patients who then need care for ADL. the directions to provide home care services. This report is aimed to provide the directions for the 2. Health Care Law for the Elderly and Development further development of the home care services in Korea, of a Visiting Nursing System through comparison of the home care system and visit- To improve the level of welfare for the elderly in ing nursing activities to the elderly in Japan and Korea. Japan, the Welfare Law for the Aged was created in 1963, in which the roles of home-helper, nursing home METHODS and special nursing home were addressed. But the num- ber of elderly who occupied hospital beds increased To compare the differences and similarities in each rapidly. People over age 65 occupied 46 percent of all country, a review was done of official materials such as hospital beds and had a 50-day average length of stay Health and Welfare Statistics, the Health and Welfare (Ikegami & Campbell, 1995). This rose to 63.5 percent White Paper, Social Indicators, and literature on commu- in 1996 (JHWSA, 1999a). The reason for the increase nity health nursing related to the care of the elderly and was that elders and their families preferred hospitals to to welfare services. For clarity, pertinent information is welfare institutions. This is the so-called social hospital- tabulated and includes; health care policy and social wel- ization of the elderly (Tatara, et al. 1993) and it in- fare facilities for the elderly. creased the cost of health care for the elderly. In order to reduce social hospitalization, the Japanese RESULTS government developed measures for both institutional care and home care on both the welfare side and the 1. General Characteristics health care side. On the health care side, the Health and The average life expectancy in Japan is higher than any Medical Service Law for the Aged (HMSLA) enacted in other country in the world (KNSO, 2000). The life ex- 1983, enabled visiting nursing services from hospitals to pectancy in Korea is also becoming longer, it was 71 be paid through the insurance system. Through a revi- years for men and 78.6 years for women in 1998 sion of the HMSLA in 1992, the Visiting Nurse Service (KHWWP, 2000). Although Japanese live longer than Station (VNSS) was established in 1992 as a new re- Koreans, the differences have narrower over the past 20 source in the community. The VNSS made it possible for years, from 10 years in 1985 to 4 years in 1998. nurses to become heads of health care organizations, a The number of elderly living with one of their children truly innovative act for nursing in Japan (Murashima, et decreased from 79 percent in 1980 to 54.4 percent in al. 1998 a). (JHWSA, 1997), but it is still a large pro- To promote health and welfare services for the elderly, portion. It was 58.3 percent in Korea in 1998 (KIHASA, the Japanese government started the Gold Plan in 1990 1998). The average number of people per household has (It was named as Gold Plan to mean Ten-year Strategy decreased to 2.79 in Japan and 3.22 in Korea in 2000. on Promotion of Health and Welfare Services for the From these phenomena, it is possible to conclude that it Elderly. It set goals to increase both institutional care will be difficult to provide good care for the well elderly and home care services). The Gold Plan was revised in if only family members provide care. 1994 as the New Gold Plan (JMHW, 2000b), to establish Next, many elderly have a chronic disease for which the VNSS as one of the essential agencies in the commu- they need help. In Korea, 86.7 percent of the elderly nity. Recently, a group home for demented elders was have chronic degenerative diseases and 34 percent have formally introduced under the Gold Plan 21. difficulty in Activities of Daily Living (ADL) (KHWWP In Korea, the Welfare Law for Elderly was enacted in 2000). The proportion of people with dementia has in- 1981, and the law to provide home care was enacted in creased in both countries, to 7.2 percent in Japan, and 1990. At that time the government emphasised hospital- 8.3 percent in Korea (JHWSA 1999 a; KHWWP 2000). based home care and over the past 7 years hospital While the most common causes of death at age 65 years based home care projects have been developed in 44 and over in both countries are malignant diseases, cere- hospitals (KIHASA, 1997a). This has now been extend- brovascular diseases (CVA), and heart diseases (JMHW, ed to hospitals nation wide under the Home Care Law 2000 b; KNSO 2000), CVA also frequently causes se- (Medical Law, 2000). The law included details on home 1168 Journal of Korean Academy of Nursing Vol. 31, No. 7 care services, home care nurse qualifications, definitions The major difference between home care services and of service user, service process and prescription, person- visiting nursing services is that home care is provided to nel for home care, and documentation. Through the law patients who have been discharged from the hospital and home care can be reimbursed through the government contains a major medical component. Visiting nursing insurance program (Table 1). provides rehabilitative and preventive care to people with chronic diseases or disabilities in the community. 3. Home Care Service and Visiting Nursing Service In Japan, there are hospital based home care services In comparison to 1970, care of elderly with chronic and community based home care services. Hospital diseases or disabilities has become a big problem in based home care services are aimed to shorten the hos- modern Japan and will become a problem in Korea in pital stay period and community based home care ser- the near future. The background demographics show vices are intended to care people with chronic diseases that the present informal service is no longer adequate at three level of agencies, that is, ward(Ku in Korea), and formal services must be considered in both coun- health center and VNSS. tries. In Korea, community based home care services can be Generally the home care system includes visiting nurs- provided only at the health center. There are no VNSS ing services. Home care can be classified as ‘hospital in the community in Korea. In the strict sense, hospital based home care’ and ‘community based home care’. based visiting nursing service can be said as home care

Table 1. History of Health Policy in Japan and Korea Japan Korea 1937 Public Health Center Law 1947 PHC Law amended 1951 Medical Service Law 1956 Public Health Center Law 1976 Revised Medical Law 1977 Medical Insurance 1982 The Health Service for the Aged Law 1981 Welfare Law for the aged 1983 Health and Medical Service Law 1989 Medical Insurance for all 1990 The Gold Plan 1991 Home care nurse system 1993 Revised Welfare Law for the elderly 1994 The New Gold Plan Community Health Law 1995 Health Promotion Law Public Health Center Law to Community Health Law 1997 Long-Term Care Insurance Law 1997 Revised the Welfare Law for the Elderly 2000 Establishment of LTC Insurance Gold Plan 21 2000 Law for Home Care

Table 2. Number of Social Welfare Facilities for the Elderly in and Korea Facility Japan*(population 126,486,000) Korea**(population 47,300,000) Geriatric Hospital 1,701(17.9%) 9(1.5%) Geriatric Intermittent Facilities 2,368@ Health Center 847 269 Municipal 1,212 2,045 Welfare Service Center 2,190 238 Community Welfare Center 109 Day Service Center 3,261 10 Short Stay Facilities 11 10 Special Nursing Home 4,214@ 53 Home for the Aged (100,000person) 947 200 Visit Nursing Service Stations 4,354 44ф * JMHW, Annual report of social welfare in Japan, 2000 **KMOHW, Health and Welfare White Paper in Korea, Dec 1998 ＠ JHWSA, Annual report of social welfare in Japan, 1999b ф Hospital based home visiting facility Kim et al. Comparison HCS Japan and Korea 1169 in both countries (Table 2). respite care, and day care. There are five thousands of Among home care services facilities in Japan, the home care service agency in Japan. Most Japanese recog- VNSS has some important characteristics that deserve nize and use home care without reluctance, not only for note. First, visiting nursing services were provided for poor people, but also for middle class people (JHWSA, the elderly from the beginning and then enlarged to in- 2000). clude all people. Second, nurses can become managers In Korea, the national focus has been on hospital of a VNSS. Third, the nurses have networks in the VNSS based home care and the number of hospitals with a and a 24-hour support system (JHWSA, 2000). Fourth, home care service has been limited. Therefore, receiving there is a wide variety in the agencies establishing VNSS, home care services is still difficult for both the general for example: local public organizations, local medical in- population and the elderly. stitutions, social welfare corporations, insurance corpora- tions, nurses associations, and doctors associations. They 4. Qualifications for Home Care Nurses and for can establish and govern VNSS as they are authorized Visiting Nurses by the Prefectural governor and meet the legal require- In Japan, home visiting nurse service has been growing ments (Japan International Social Security Association, very rapidly and the number of nurses who work in 2000). These four remarkable characteristics are some- home care settings is larger than that in public health set- thing to which other countries can refer. tings. The system of VNSS was established in 1992 In Korea there are 41 hospitals and 3 general clinics through a revision of the HWSLA and the number of providing home care nursing. The cost of home care is VNSS has increased rapidly from 516 in 1994 to 4,470 covered by clients and by medical insurance (20:80). At in March 2000 (JNS, 2000). The number of visiting nurs- the community level, the health center provides home es in 1998 was 12,289 (Notes. The data of nurses work- care free of charge. The independent type of home care ing at VNSS are from Report on Public Health agency is rare there only being one, the Home Care Administration 1998 : JMHW, 2000a). Nursing Station in the College of Nursing, Seoul In Korea, home care nurses (HCNs) and visiting nurses National University, which is under a research project (VNs) are working at different settings. Most HCNs (KIHASA, 1997a, 1997b; Yun, 1998). This agency was work in hospital based home care settings while VNs established as only a model project. In reality, there are work in the health centers. no restrictions on the establishment of hospital based However, for an efficient system, the quality of the home care within the definitions given in the law, though home care nurse is very important. In this aspect, the proprietary home care agencies have not yet been sanc- two nations have developed in different ways. Japan has tioned (Table 3). focused the actual home care nursing services, and VNs In Japan today, it is not difficult to get home care ser- created the Japan Visiting Nursing Foundation (JVNF) in vice including visiting nurse service, home-help services, 1992. Because Japan has not formal curriculum to be

Table 3. Home Care System in Japan and Korea Japan* Korea** Presence Subject Presence Subject Discharged Hospital Present Present Discharged For medical care 65 years old and over Ward Present None - for prevention bed ridden 65 years below Low income & all Community Health Center Present for incurable disease & Present ages for ADL mental problem independence & care All ages VNSS Present None - For ADL independence * Japan has two-type VNSS. One is VNSS for the elderly. Another is VNSS for the general population. ** Korea has Home Care Center in one university and in one Seoul Nurses Association, these are different from VNSS. 1170 Journal of Korean Academy of Nursing Vol. 31, No. 7

HCNs, the rapid increase in VNSS has resulted in a defi- 1999b). cient number of qualified visiting nurses. According to the report of the VNA in Japan, visiting On the other hand, Korea focused on cultivating quali- nursing includes screening of health status and psychoso- fied nurses through a HCNs training. The Medical Law cial support as the most frequent activities. The next accredited home care nursing as one branch of special- most frequent activities were care for recuperation, med- ized nursing in 1990. The KNA (Korea Nurses ical treatment, and rehabilitation by Physical or Association) established the Korean Academic Society of Occupational Therapists (JHWSA, 2000). The cost of Home Care Nursing in 1993 (KASHCN, 1995). In 1990, these activities is calculated by the time required to pro- the first six-month training program for certification as a vide care (one unit is 30 minutes) and is for comprehen- HCNs was given to forty nurses at the graduate school sive care, for example, health check, consultation or re- level. Now 11 of 48 universities in the country provide habilitation by a nurse. such programs (Yun, 1998). To be certified as a HCN, it In Korea, items for hospital based home care services is necessary to receive 600 hours of education. The num- include basic care, laboratory, medication, education, ber of HCNs was 2,650 in 2000 (KNA, 2001). and therapeutic care and training. In basic care, vital sign monitoring was the most frequent activity, followed by 5. Major Diseases and Contents in Home Care Intake/Output, position change, and back care. Among Nursing them only the latter two were covered by medical insur- The disease most frequently found in home care nurs- ance. In medications and injections, IV therapy was the ing was CVA (Table4), and in hospital based home care, most frequent. Therapeutic care and training, including cancer was most. Almost users in both countries are the suture removal, wound care, bed sore care, bladder irri- elderly. gation, gastric nutrition, urinary catheter insertion, Home care nursing activities also show some differ- Oxygen therapy, cannula care and drainage care, all of ences as well as some similarities. Home care nursing in which are covered by insurance (Yun, 1998). Japan is divided in three areas: long-term care for the el- Many of people who use home care services are elder- derly, high tech home care, and terminal care. When a ly, and working, 68.5 percent in 1993 and 67.4 percent VNSS is organized emphasis is on providing care for the in 1994. According to a report on home care services in elderly to maintain their health status, but these days the city of Seoul, the major components of home care more high tech care, such as changing catheters, tubes, are as follows; health management, patient management, dressing, drug administration, physical exams, functional circulating services, continuity service (Seoul Metropoli- training as well as terminal care have become a necessity tan Bosa Hwangyongguk inside report, 1995). at home. According to the report of the Visiting Nursing Association, 88.6 percent of the user of home care nurs- 6. Other Nursing activities for elderly in the communi- ing was the elderly, age 65 years and over, and 80.9 per- ty cent was 70 years and over (JVNF 2000; JHWSA, Community health nursing has two aspects; one is

Table 4. Percentage of Patients According to Selected Disease and Home Care Service Facility in Japan and Korea Japan Korea VNSS1 Hospital based2 Community level2 Independent Type3 Disease % Disease % Disease % Disease % Circulatory 52.4 Cancer 40.3 Circulatory 53.3 Circulatory 54.6 Musculoskeletal 8.2 CVA 17.1 Musculoskeletal 9.5 Cancer 23.2 Nervous 7.6 Post C/S 11.0 Dermatologic 9.3 Musculoskeletal 7.0 Mental & behavioral Fracture 4.7 Endocrine (DM) 5.6 Urogenital 7.0 like dementia 6.8 Endocrine(DM) 4.2 Urogenital 5.4 Digestive 2.8 Neoplasms 5.2 Respiratory 4.0 Neoplasm 4.5 Endocrine 1.6 Endocrine (DM) 4.3 Sore 2.3 Respiratory 3.9 Postpartum 1.6 Paralytic 2.1 Digestive 1.1 1JHWSA, 2000, 2Ryu, HS et al., 2000 Refer from hospital (1993-1999), 3Park, JH et al., 2000 Some data were recalculated by disease regrouping Kim et al. Comparison HCS Japan and Korea 1171 nursing at home (home care) and the other is care for European countries have modified their long-term care the whole community (). In Japan, policies. Actually, there are movements to decrease the public health nurses who work at the municipalities per- amount of institutionalization of elderly people and de- form public health nursing by providing preventive care, velop sheltered housing units with around-the clock care such as health examinations, and health education based by nurses and home help services. Around-the-clock on the Community Health Law 1994. The number of care has spread all over Denmark and the Scandinavian public health nurses work at the municipalities was countries (Cates, 1993). These countries have held con- 28,000 in 1998 (JMHW, 1999b). stantly or reduced the number of institutionalized elders In Korea, health centers provide health examinations. (Coleman, 1995). The basic content includes 12 items. In this examination, For elderly care, all facilities including hospitals, inter- the most frequent health problem was cerebrovascular mediate facilities and nursing homes are equivalent in disease. The health centers also provide visiting nursing importance. If this is so, to increase the number of facili- services to the people in their communities. ties is not the best way. What Japan has done is to re- duce the number of institutions for elders. And now, for DISCUSSION the elderly in Korea, the home is becoming a field for caring and the most convenient place to live. The principal approach to providing health care related What are the barriers, and what is the best way to ad- to the shortage of resources was institutionalization be- vance the home care system? Here we need to consider fore the introduction of home care nursing. This phe- cultural aspects. Confucianism is strong in both Japan nomenon was more apparent in Japan than in Korea and Korea, and this makes it difficult to use welfare facil- (The number of elders institutionalized is up to 609,394 ities with ease. For example, in Japan elders and families in Japan in 1998: 190,457 in GIFS (JMHW, 1999): prefer to use hospitals rather than nursing homes, be- 266,568 in Special Nursing Homes (JMHW, 2000b): cause people feel ashamed if they have to use welfare fa- 173,073 in Geriatric Hospitals (JMHW, 2000b). But the cilities (Tatara et al., 1993). Korean elders and their fam- shortage of hospital beds and increased medical expens- ilies also prefer hospitals to PHC or other facilities when es led to the Gold Plan in Japan in 1990, which resulted they have a disease or when they are ill. in an increase in the number of institutions, as well as Furthermore, adult children have a strong sense of re- home care services, such as day care centers, home- sponsibility for their parents. In a survey, 87.3percent of helpers, and visiting nurse service stations. Although, subjects, in both urban and rural areas, reported feeling Japan considers the number of facilities not to be suffi- responsible for their elders. There were only 3 percent cient and reports that only 21 percent among the esti- who felt that responsibility lies in the social welfare sys- mated number of elderly who need care, 2.8 million was tem or others (KIHASA, 1996). Accordingly, if they do admitted to institutions in 2000 (JMHW, 1998). not take the ill elderly to a hospital, they feel they are During the past ten years, a remarkable characteristics neglecting them. in Japan is the system evolving away from a system that Murashima et al reported that around-the-clock-in- focuses on treating illness in hospitals toward one that home care for the elderly was effective in Japan emphasizes prevention and disease management and (Murashima, et al, 1999a). Visiting nurses gave confi- supports independence of elderly in their own homes dence to the community residing people. The people (Kolanowski, 1997). Korea still relies on hospitals over who have hesitated to use home care services began to other facilities. Although home care service was intro- use them without hesitation because community resi- duced seven years ago, has focused mainly on hospital dents could use the visiting nursing services as one of based home care, and the activation of visiting nursing the medical care resources rather than as a welfare re- in the health centers has a little increased as the health source (Asahara & Momose, 1995). Some public health care options for the people of Korea in home care sys- nurses created VNSSs in their own communities tem. (Murashima et al, 1999a; 1999b; Okada, 1997). The av- On this point we need to examine the situation in oth- erage length of stay in hospitals decreased from 50.5 er developed nations. Faced with a growing number of days in 1990 to 40.8 days according to “census on med- elderly people and the rising costs of health care, several ical care institutions and hospital reports 1998” (JH- 1172 Journal of Korean Academy of Nursing Vol. 31, No. 7

WSA 1999). In A. Jamieson (Ed.). Home Care for Older People in Europe, One factor to strengthen the use of home care can be (pp. 3-12). Oxford University Press, Oxford. Japan International Social Security Association. (2000). Outline of confidence of community residents to home care nurse. Social Insurance in Japan in 1999, JISSA, 3-23, 43-52 As another factor to strengthen the use of home care JHWSA. (2000). Homonkango Zittai Chyosa in 1999[research on nursing can be thought the health center. Among those actual condition in visiting nursing 1999] (in Japanese) Tokyo: JMHW. who visit the health care center in Korea, 44 percent are JHWSA. (1999a). Statistical Abstracts on Health & Welfare in elderly. So home care services which are provided at Japan, JMHW. health center level are also be very important to pro- JHWSA. (1999b). Kokumin Fukusi no Doko1999, [Annual Report mote the use of home care. of Social Welfare in Japan 1999] (in Janese). Tokyo: Kyosei Tokei Kyokai, 181-227. 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